Washplus.org

Water, Sanitation and Hygiene (WASH) Considerations
for Accelerated PMTCT Programming

Why WASH Matters
Many life-threatening opportunistic infections are caused by exposure to unsafe water, inadequate
sanitation and poor hygiene. Diarrhea, a very common symptom that can occur in people living
with HIV and AIDS (PLHIV), affects 90 percent of PLHIV and results in significant morbidity and
mortality, especially in HIV-positive children. Diarrhea reduces a body’s ability to absorb life
saving medicines and nutrients in food, feeding the cycle of malnutrition, which further
exacerbates the effects of HIV. There is tremendous irony in washing down life saving medicines
with water that can kill.
Studies have shown that children 7-14 months of age show an increase in diarrhea after being
exclusively breastfed and this is linked to the introduction of complementary feeding. While
previously it was thought that unsafe water was the primary cause, recent evidence is also
pointing to unsafe food.
In this era of treatment and increased emphasis on Prevention of Maternal to Child Transmission
(PMTCT), nevirapine is used both as a treatment and prevention method. Experience on the
ground indicates that in areas where nevirapine syrup is scarce, programs are crushing tablets and
mixing them with water to feed to babies. Unfortunately, the water used to soften the tablets is
often unsafe and will compromise the effectiveness of the intervention by causing diarrhea.
If clients choose replacement feeding, intensive counseling is essential to encourage AFASS
compliance. Achieving AFASS or “Acceptable, Feasible, Affordable, Sustainable and Safe” is just
not possible in a fecally contaminated environment. Countries frequently have stockouts of
formula, forcing a patchwork of replacement feeding, often mixed with untreated water sources
and served in unhygienic conditions.
Safe Water, Hygiene, Handwashing and Sanitation Reduce Diarrhea in PLHIV
At least 30 percent of diarrheal diseases can be prevented through integrated programs involving
the provision of water treatment and safe storage, safe feces disposal, and promotion of key
hygiene practices.
• Treatment and safe storage of drinking water at point of use reduced the frequency by 25% and severity of diarrhea by 35% in PLHIV (Lule et al. 2005). • Presence of a latrine was associated with reduced diarrhea risk by 31% and number of days • Presence of soap, a proxy for handwashing, was associated with reduced number of days ill
Safe Water Treatment and Soap are an Effective Incentive for Early and Increased Enrollment
into PMTCT Programs
Distribution of a “safe water kit” that includes a water treatment product, water storage container
and soap, has proven to be an effective incentive to increase use of antenatal care services (ANC),
HIV testing services, and facility delivery. Households receiving free safe water kits were also
more likely to be purchasing WaterGuard one year after receiving the free kit, using water
treatment products regularly, and their neighbors were more likely to do the same. Studies show
that ANC visits also increased by 10-15 percent. This type of incentive program may be helpful in
bringing new clients into PMTCT who might not generally get there (Sheth et al. Am J of Trop Med,
2010).
WASH Considerations for PMTCT Accelerated Planning
To improve the quality and effectiveness of PMTCT interventions and for basic prevention of diarrhea in
children, ensure that mothers and HIV-exposed and infected children have access to safe water,
handwashing, safe feces disposal, and food hygiene in both the household and facility-based care settings.
Key Programmatic Considerations for Accelerated Plans include infection control through:
Water safety - Incorporate treated water into clinical regimens and household practice. Families need
access to home-based, water treatment methods and safe storage options in communities without a reliable
source of safe water. Hypochlorite solution (most commonly known as WaterGuard) or tablets (commonly
known as Aquatabs or WaterGuard) are the preferred water treatment method because the residual
chlorine protects water from recontamination for 24 hours; however, acceptable options include boiling,
solar disinfection (SODIS) and silver-colloidal filters. PuR is highly effective hypochlorite powder with
extra ingredients for turbid water, but quite expensive so not sustainable if not regularly donated.
Include in accelerated plans:
Integrate water treatment options and education on safe household storage into PMTCT programming. WaterGuard is often included as part of the basic care package, but counseling is essential to assure consistent and correct usage. Only give a baby treated water or replacement and complementary foods mixed with treated water. If clinics must grind and mix nevirapine or other treatment, mix only with treated water.
Handwashing with soap - Incorporate handwashing into clinical regimens and household practice.
Programs can place handwashing stations with soap or soap substitute such as ash in facilities, community
care points and in the households. Programs in water scarce situations should consider installing and using
the “tippy-tap,” a simple plastic jug, gourd or local material that regulates the flow of water to allow for
handwashing with a very small quantity of water. Critical times for handwashing include:
 Before and after caring for patient  After defecation  Before preparing food or medicine  Before feeding or breastfeeding  Before eating Food hygiene - In home and childcare settings:
Feed child food that is piping hot, not just warm. If child must be served food that is previously cooked and sitting, reheat before serving.
To improve intervention quality and effectiveness, the following cross-cutting measures are
recommended:
Strengthen provider competencies and practice to provide counseling to mothers on water treatment, infection control (handwashing) and food hygiene. Use water treatment solution and soap as an incentive to enroll pregnant women into PMTCT

Source: http://www.washplus.org/sites/default/files/wash-pmtct_final.pdf